SUSAN NEWTON is associated with a private practice oncology office in Dayton,
Ohio, and is clinical affairs manager, oncology, at Ortho Biotech Oncology,
also in Dayton.

Oncology nurses aren't the only ones who must
worry about the safe handling of chemotherapy agents. More and more, ICU and
med/surg nurses are administering these drugs, too. If you were asked to administer
a drug like fluorouracil, would you know how to do so safely?

Jump to:

You're working the evening shift on a med/surg unit. Your first admission
is a 59-year-old male with rectal cancer. He needs to receive a continuous infusion
of chemotherapy and the oncology unit is full. Your first response is, "How
do I administer this chemotherapy? I don't want to touch it!"

No doubt about it, the cytotoxic drugs used in cancer chemotherapy are hazardous.
They work by disrupting the growth and reproduction of cancer cells. Unfortunately,
that action often afflicts certain healthy cells as well, causing toxic side
effects in the patients who receive chemotherapy and posing health risks to
the nurses who administer it without taking protective measures.

Increasingly, patients are being given chemotherapy outside of the oncology
unitmost often in outpatient centers, but also in ICUs and med/surg units.
In addition, drugs typically used for cancer chemotherapy are also prescribed
for conditions other than cancer, such as arthritis or multiple sclerosis. So
even if you are not in oncology, at some point you may have to administer these
agents. Knowing the recommended safety procedures for handling them is essential
for protecting yourself from accidental exposure.

Repeated exposures are especially dangerous

The chemotherapy drugs nurses are most likely to administer are paclitaxel
(Taxol); doxorubicin HCl (Adriamycin, Doxil); cyclophosphamide (Cytoxan); cisplatin
(Platinol); docetaxel (Taxotere); etoposide, which is commonly known as VP-16
(VePesid); methotrexate; fluorouracil, which is commonly known as 5-FU (Adrucil);
and carboplatin (Paraplatin).

Accidental exposure to such agents can occur in several ways: by direct absorption
of a drug through the skin; by ingestion while eating or drinking after hand
contact with a drug; and by inhalation of airborne droplets.

You may have an exposure without realizing it. In a study of 83 nurses and
pharmacists who handled or administered chemotherapy drugs, a specialized scanning
device revealed that 13% of the group had one or more spots of drug contamination
on their gloved or ungloved hands, gowns, or shoes.1

The adverse reproductive effects associated with occupational exposure to
these drugssuch as temporary and permanent infertility, birth defects,
menstrual dysfunction, ectopic pregnancies, and spontaneous abortionshave
been documented in a number of studies.2,3

One study compared the reproductive outcomes of 663 women. 4 About
one-third were oncology nurses, one-third were non-oncology nurses, and the
other third weren't nurses at all. The percentage of birth defects was 3.1%
for oncology nurses, 1.5% for the non-oncology nurses, and 0.3% for the non-nurses.

It's more difficult to connect long-term exposure in healthcare workers to
an increased risk of developing malignancies because of the time interval between
exposure and the onset of malignancy. It's also difficult to differentiate the
influence of individual risk factors for cancer from occupational ones.

Some studies have found increased chromosomal aberrations and evidence of
mutagenicity in the urine of nurses who handle cytotoxic drugs, while other
studies have failed to find a relationship between exposure and these measures.1,2
These disparate results may be due to differences in levels of exposure between
studies, differences in the use of personal protective equipment (PPE) and work
techniques, and differences in urine collection timing.2

While the long-term effects on nurses who are occupationally exposed to these
drugs require further study, much research has already been done on the long-term
effects on patients receiving chemotherapy. The development of secondary malignancies
such as leukemia, bladder cancer, and lymphoma is well documented.2

Tips for minimizing your risk of exposure

To learn how to handle chemotherapy drugs in a safe and conscientious manner,
you should ideally have formal classroom training as well as hands-on competency
training. Most facilities offer such training and prohibit nurses from administering
chemotherapy without it.3 At minimum, you should be instructed on
safe handling procedures.

The Oncology Nursing Society (ONS) provides comprehensive guidelines on administration
(Chemotherapy and Biotherapy Guidelines and Recommendations for Practice)5
and a separate set of guidelines on safe handling (Safe Handling of Cytotoxic
Drugs: An Independent Study Module).6 Much of the following information
is based on ONS guidelines, which include the recommendations of the Occupational
Safety and Health Administration (OSHA).2

Preparation. Be sure to follow your facility's policies and
procedures when preparing to administer chemotherapy. When a patient who needs
chemotherapy arrives at your unit, the first thing you should do is double-check
the chemotherapy orders with a nurse from the oncology unit and send the orders
to the pharmacy. Making sure that your patient is well informed of the process
and has received adequate teaching about the potential side effects of the drug(s)
is a standard of care for chemotherapy patients.

Put on PPE that includes a disposable, fluid-resistant, closed-front gown;
disposable, powder-free gloves with a thickness of at least 0.007 inch that
cover the gown cuff; and goggles or other eye protection.6 It's important
to wash your hands both before you put on and after you take off gloves.

Next, using either your patient's existing vascular access device or an IV
that you initiate, infuse an appropriate IV solution that's compatible with
the specific drug to be administered.

If you're administering chemotherapy in a hospital, it's likely that the drugs
used will be prepared in the pharmacy. IV bags with chemotherapy drugs must
be spiked in a biological safety cabinet or hood. To prevent having to spike
bags at the bedside, new tubing should be connected to each bag of chemotherapy
before it's sent to the nursing unit. IV tubing should also be primed with a
non-drug solution before the chemotherapy drug is added, or a back-flow closed
system should be used.2

If at any point you need to transport chemotherapy, make sure you do so properly.
The chemotherapy bags should be placed in another bag and appropriately labeled
as chemotherapeutic agents. Many facilities use a hard-plastic carrying case
for these drugs. A pneumatic tube system should never be used to transport them.

Administration. When the chemotherapy arrives, double-check
the dose for accuracy with another RN. When administering chemotherapy, it's
important to use a main IV line to provide direct access to the patient in the
event of an adverse reaction to the chemotherapy drug.

Before administering the drug, verify the patency of the IV site. Extravasation
can cause severe damage to tissue, especially in the case of vesicant drugs,
which should be infused via a central IV line. Instruct your patient to immediately
report any pain, irritation, redness, or swelling at the IV site.

Place a disposable drape under the patient's arm where the tubing from the
chemotherapy bag will be connected. Hang the chemotherapy bag on the pole of
your infusion pump, remove the cap from the tubing, and then use a Luer-Lok
to connect the tubing to the main line on the IV port closest to the patient.
Set the pump to infuse at the rate ordered.

Waste disposal and spills. After infusion is complete, promptly
dispose of any equipment that contains or contained the drug. Wrap the equipment
in the disposable drape from under the patient's arm and place it in a leak-proof,
puncture-proof container that's clearly marked as "biohazard waste," "infectious
material waste," or "chemotherapy/cytotoxic drug waste." Your facility should
have these containers available and accessible wherever chemotherapy will be
administered.

If a spill occurs at some stage during infusion, ideally, specially trained
personnel should clean it. However, if that's not possible and you have to clean
it, be sure you're still wearing PPE, including eye protection, before you begin.
The materials you use to clean a spill should be disposed of in an appropriate
biohazard container.

Because chemotherapy agents may be excreted in body fluids, the patient's
urine and stool (and, to a lesser degree, his saliva, emesis, perspiration,
mucus, and tears) may be contaminated for 48 hours after the last drug dose.
Wear PPE when handling such excreta, and wash your hands after removing your
gloves. Glassware or other contaminated reusable items should be washed twice
with detergent by a trained employee wearing double latex gloves and a gown.2

Check your facility's policies about handling linen that's been contaminated
with chemotherapy. Generally, any linen contaminated with the body fluids of
a patient who receives chemotherapy should be placed in specially marked laundry
bags and then placed in a second impervious bag that's also labeled.2

Accidental exposures. If a chemotherapy drug comes into contact
with your skin or a patient's skin, thoroughly wash the affected area with soap
and water, but don't abrade the skin with a scrub brush.7 If the
drug gets in your eye(s), flush with copious amounts of water for at least 15
minutes while holding back your eyelids. Then get evaluated by employee health
or the ED. Be sure to follow your facility's policies and procedures for reporting
such incidents.

The bottom line is that all nursesnot just those who work in oncologyshould
know their hospital's policies and procedures on safe handling and administration
of chemotherapy agents. Believing that you'll never have to handle these agents,
and thus being unprepared if asked to do so, could be harmful to your health.